腹腔镜下手术治疗先天性胆总管囊肿198例分析

Clinical experiences of laparoscopy for congenital choledochal cyst:a report of 198 cases

目的：探讨腹腔镜下手术治疗先天性胆总管囊肿的中短期效果，总结临床体会。方法回顾性分析2006年10月至2014年4月我们收治的198例腹腔镜下胆总管囊肿患儿临床资料。其中男性53例，女性144例；年龄1个月至13岁，平均年龄38.2个月。临床特征：102例为间歇性右上腹痛，25例黄疸，7例排陶土便，13例存在腹部包块，45例有肝功能损害，31例血淀粉酶升高。均予囊肿切除、肝管－空肠 Roux-en-Y 吻合术。总结分析术中、术后及随访情况。结果198例患儿囊肿直径1～20 cm，平均4.26 cm，其中囊状扩张186例，梭型扩张12例。Todani’s 分型 I 型191例，IV 型7例。198例中，19例中转开腹手术，其中9例炎症粘连剧烈，4例肝总管细小，2例囊肿突入十二指肠，2例囊肿巨大术野暴露不清楚，1例腹腔镜下无法确认肝管，1例见右副肝管。其余179例顺利完成腹腔镜下胆总管囊肿切除、肝管－空肠 Roux-en-Y 吻合胆道重建术。手术时间130～480 min，平均255 min。术后6例出现胆漏，3例出现吻合口狭窄，其中5例再次行开腹手术。1例出现输入袢粘连绞窄坏死，重新行Roux-en-Y 吻合。1例出现粘连性肠梗阻，经保守治疗好转。其余病例随访3个月至8年，无并发症，肝功能均正常。结论腹腔镜下手术治疗先天性胆总管囊肿具有切口小、暴露清晰、恢复快等优点，但对术者要求较高，术中操作困难时及时中转开腹手术，可降低手术风险，减少并发症的发生。

Objetive To explore the short and medium-term outcomes of laparoscopy for congenital cho-ledochal cyst and summarize its clinical experiences. Methods From October 2006 to April 2014,a total of 198 cases of laparoscopic excision of choledochal cyst,hepatic duct jejunal Roux-en-Y anastomosis were retro-spectively reviewed.Perioperative analyses and follow-up observations were conducted. Results There were 53 males and 144 females with an average age of 38.2 （1 ~156）months.The symptoms included 102 cases with intermittent right upper abdominal pain （n =102）,jaundice （n =5）,clay stool （n =7）and abdominal mass （n =13）.There were 45 cases with liver function damage and 31 cases with elevated serum amylase.The average cyst diameter was 4.26 （1 ~20）cm.The dilatation was cystic （n =186）and fusiform Ⅳ（n =7）.A-mong 19 cases of converting into open surgery,there were acute inflammatory adhesion （n =9）,miniature he-patic duct （n =4）,cyst protrusion into duodenum （n =2）and huge cyst with indistinct exposure of operative field （n =2）,laparoscopic non-confirmation of hepatic duct （n =1）or right accessory hepatic duct （n =1）. The remaining 179 patients successfully completed laparoscopic excision of choledochal cyst,hepatic duct jeju-nal Roux-en-Y anastomosis biliary reconstruction.The average operative duration was 255 （130 -480）min. The postoperative outcomes were bile leakage （n =6）,anastomotic stenosis （n =3）and repeated open opera-tion （n =5）.One case of afferent loop adhesion strangulation and necrosis underwent Roux-en-Y re -anasto-mosis.One case of adhesive intestinal obstruction recovered through conservative measures.The remainder had no postoperative complications and liver functions were normal.Conclusions Laparoscopy for congenital cho-ledochal cyst offers obvious advantages of smaller incision,distinct exposure and faster recovery.However,op-erator proficiency is required.During difficult operations,timely conversion into laparotomy may lower opera-tive risks and complications.